Adolescents and young women are increasingly seeking cosmetic genital surgery.1-3 A growing area of concern is the appearance of the external genitalia and, in particular, the size and shape of the labia minora. Enlarged labia remain a poorly defined clinical diagnosis. 4 Once considered a variant of normal anatomy, enlarged labia have recently driven a growing interest in labiaplasty. The symptoms, diagnosis, and treatment options for clinically enlarged labia are reviewed here.
SYMPTOMS AND DIAGNOSIS
Originally described as protuberant tissue projecting beyond the labia majora, there is no consensus among gynecologists or plastic surgeons regarding objective criteria to confi rm the diagnosis of clinically enlarged labia. In an early description, Friedrich classifi ed labia minora as enlarged when the maximal width between the midline and the lateral free edge measured greater than 5 cm.5 Others have defi ned the normal width of the labia minora to be less than 4 cm.6
Typical symptoms can be functional and/ or psychologic.6-10 Enlargement of either one or both labia can result in pain, irritation, recurrent infection, poor hygiene, and interference with certain activities such as sexual function or athletics. Commonly affected sports include running, cycling, horseback riding, and swimming.
In addition, concerns regarding the appearance of the labia can result in considerable psychologic and emotional distress, particularly during adolescence.10 Adolescents may be reticent to change their clothes in front of peers if they are self-conscious about the appearance of their external genitalia. For example, a young girl may report the need to "fold up" her labia and push them into her vagina in order to reduce the appearance of excess tissue or a "bulge" in her underwear or bathing suit.
On occasion, concerns regarding labial size or asymmetry can be alleviated by reassurance that variations in size and shape are considered normal anatomy.4 It is important to remind adolescents that the media's perception of genital anatomy is often not representative of the general population. Furthermore, functional symptoms can be managed through counseling regarding personal hygiene and avoidance of form-fitting clothing. If symptoms persist after medical management, surgical options can be discussed.
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PHYSICAL EXAMINATION
It is paramount for the examining physician to be familiar with the external female genitalia of adolescents and young women, including the normal variations. A systematic approach to the physical examination should be used. The hair distribution, skin, labia majora and minora, clitoris, urethral meatus, introitus, perineal body, and anus should be inspected. In addition, the labial minora should be fully extended laterally to measure the distance from the midline to the lateral free edge and to evaluate for asymmetry (Figure 1). It is also important to rule out other etiologies for labial/vulvar symptoms (eg, pain, irritation), such as reaction to hair removal, skin conditions such as eczema or psoriasis, or vulvar gland irritation/ infection.
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DECISION AND TIMING OF SURGICAL TREATMENT
The goal of labioplasty is to resect the excess labial tissue while creating symmetrically reduced labia. The exponential growth in cosmetic surgery has fueled a growing interest in genital plastic surgery, and thus significant ethical issues arise in the adolescent patient population. Cases of profound labial enlargement or asymmetry that are symptomatic for the young woman should be addressed surgically. Some adolescents or young women seek elective genital surgery in hopes of increasing self-esteem or improving sexual function and cosmesis, and these cases should be approached with great caution and high ethical standards.
Patients should be extensively counseled regarding the lack of long-term data on surgical outcomes.1,3 They should be aware that cosmetic genital surgery may result in scarring, which in rare instances can lead to pain and dyspareunia.3 Furthermore, purely elective procedures are not covered by insurance, and cosmetic results may vary.
We offer surgery for symptomatic structural abnormalities of labial hypertrophy and not for pure cosmetic issues. Although labioplasty can be performed during adolescence, some have advocated that the minimum age should be 18. Decisions regarding surgical correction in adolescence should always involve the parent or guardian.
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SURGICAL TREATMENT
Although several techniques have been described in the literature, there are limited long-term outcome data.1,3 The simplest technique involves straight amputation of the excess tissue and oversewing the incised edge with interrupted absorbable suture (Figure 2).11 Great care should be taken to avoid the area of the clitoris and clitoral hood. With this technique, the labial edge may be replaced with a scarred suture line that in rare instances can lead to irritation and discomfort.12 Furthermore, the natural contour and pigmentation of the labia minora may be compromised.12
Several newer techniques have been described that attempt to reduce the amount of exposed scar tissue while preserving the natural contour of the labia minora.13-16 One such technique involves a wedge resection with subsequent reanastomosis. While maintaining symmetry, a V-shaped segment is resected. The edges are then reapproximated using interrupted or a running subcuticular fine absorbable suture (Figure 3). Postoperatively, patients should keep the area clean and dry, avoid strenuous activity, and wear lose clothing to protect the vulvar area from friction.
Labioplasty is considered a simple surgical procedure that is associated with a high degree of patient satisfaction.6,8,13-16 In a large case series of 163 women who underwent labioplasty, the majority reported favorable results. The most common motives for seeking surgical correction included aesthetic complaints, entry dyspareunia, discomfort with certain types of clothing, and interference with athletic activities.
The majority of subjects underwent bilateral surgical correction, and a V-shaped wedge resection technique was utilized. Ninety-one percent of patients reported an improvement in aesthetic appearance, and 96% reported a relief in functional discomfort. There were no major surgical complications. Of note, 7% underwent a second procedure because a small wound dehiscence aff ected the cosmetic result.6
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SUMMARY AND RECOMMENDATIONS
Enlarged labia minora are often described as protuberant labial tissue extending beyond the labia majora. There are no standard criteria to confi rm the diagnosis of clinically enlarged labia. Physicians routinely use labial width measurements and the presence of symptoms to guide treatment options. Common symptoms include irritation, pain, chronic infection, problems with personal hygiene, and interference with sexual activity or athletics. In addition, concerns regarding the appearance of the external genitalia can result in considerable psychologic and emotional distress. Mild symptoms can be managed conservatively through counseling regarding personal hygiene and avoidance of form-fitting clothing.
We offer surgery for symptomatic structural abnormalities of labial hypertrophy and not for pure cosmetic issues. Patients should be extensively counseled that surgical correction may lead to scarring, chronic vulvar pain, and dyspareunia. In addition, surgery is considered elective, and cosmetic results may vary. The goal of labioplasty is resection of the enlarged labial tissue and the creation of symmetrically reduced labia. The wedge resection is the most studied and published technique.
The authors report no actual or potential conflicts of interest in relation to this article.
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Jhansi Reddy, MD, is Clinical Assistant Professor, Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY. Marc R. Laufer, MD, is Chief of Gynecology, Division of Gynecology, Children's Hospital Boston, Harvard Medical School, Boston, MA.